Augusta explores models for indigent health care

By Staff Writer

The quick test at the health fair last week gave Judith Sullivan something to worry about. Her blood sugar level was high, and her family has a history of diabetes.

Like many of Augusta's uninsured, she turned to the Center for Community Health, one of the community clinics established in partnership with University Hospital. And she turned to nurse practitioner Margo Henderson.

"If I didn't have Margo as a resource, I probably wouldn't have gotten it checked out," said Ms. Sullivan, 52. "I probably would have pretended they didn't say that, that it didn't happen."

For many years, University and the Augusta Commission have been drawn into an annual dust-up over how much the commission will pay University to care for the certified indigent. The annual battle was the focus of a recent report from the special grand jury investigating Augusta government, which blasted commissioners for not understanding University's other indigent care funding from the state and by inference criticized University for not being forthcoming about it.

Both sides are loathe to continue the conflict and have been looking outside the area for a better model, such as the system in Asheville, N.C.

It sounds ideal but impossible to do in the real world of health care: getting everyone to share the burden of caring for the poor and uninsured. But in Asheville, it's being done. The Buncombe County Medical Society and community leaders got together six years ago to map out a system for indigent care that since has become a national model.

Under BCMS Project Access, about 80 percent of Asheville's physicians volunteer to take referrals of indigent patients from a centralized computer system at the medical society that ensures the burden is spread among them, amounting to $3.5 million in services last fiscal year.

The two acute care hospitals, which merged a few years ago, donated $2 million worth of lab tests, outpatient care and hospitalizations. The Buncombe County Health Center handles primary care for about 9,000 patients and refers out to volunteer physicians when needed. Neighborhood clinics also provide primary care and referrals.

Area pharmacists donate drugs at cost, and the county pays for them, about $350,000 in its last fiscal year, said Alan McKenzie, chief executive officer of the medical society and director of Project Access.

"The critical elements are a sense of community among the health care providers, including strong leadership from the physicians themselves, with support from local government, from area hospitals, from the traditional providers of care to low-income uninsured, particularly neighborhood clinics," Mr. McKenzie said.

Bringing them together in a system is the key, Mr. McKenzie said.

"I think (Project Access) recognizes that charity care exists in the community, in every community, and that each hospital, competing or not competing, every doctor, competing or not competing, every pharmacist, competing or not competing, is contributing to some extent in meeting and providing charity care in your community," Mr. McKenzie said. "What Project Access says is if you're going to do it, do it right. It's the right thing to do and the smart way to do it."

A successful model

The program already has been replicated in two other communities, Sedgwick County (Wichita) in Kansas, and Wake County (Raleigh) in North Carolina, with other areas working to put it in place. The idea has been picked up by the national United Way leadership, which is urging local chapters to explore the model in their communities, Mr. McKenzie said.

In Sedgwick County, doctors again led the charge, said Anne Nelson, Project Access director there.

"It really requires from the beginning physicians willing to take a lead in developing the program," Mrs. Nelson said.

Augusta allergist Terrence Cook was among the Augusta delegation that visited Asheville to study Project Access, and he briefed the Board of Trustees of the Richmond County Medical Society on it last week. Tentative plans are to invite Project Access leaders in January to make a presentation to a called meeting of the Medical Society that will include as many Augusta physicians as possible, said Dr. Cook, who is vice chairman of the board of trustees.

"It's a very impressive program, and we're going to look at it in a very serious vein," Dr. Cook said.

Project Access is just one of the models University officials have checked out this year, said J. Larry Read, chief executive officer of University Health Care System.

"One of the things they said up there (in Asheville) - and I'll bet this is true - is we probably have the resources in Augusta to take care of these patients," Mr. Read said. "It's just that it is disjointed and not coordinated in the appropriate manner."

Augusta Commissioner Steve Shepard, who was also part of the delegation, said the Asheville program is intriguing, but "if we continue to pursue our inquiry into this model, the physicians here will have to buy into it."

There are some significant differences between Augusta and the cities with Project Access. Asheville's Health Center and indigent clinics provide a larger primary care system than Augusta has, Mr. Read said; Wichita has five indigent care clinics that see 15,000 patients annually.

Unlike Asheville, Wichita has three competing hospitals - which is closer to Augusta's situation - although none is the designated indigent care provider. Nonetheless, there was full cooperation, Mrs. Nelson said.

"Everyone takes on the responsibility for (indigent care)," she said. "And all the hospitals agreed up front to be full participants."

Willing to talk

The CEOs of Augusta hospitals all said they would be willing to discuss the idea, although some expressed reservations about the program, particularly if there was no new funding or no sharing of funding.

"It wouldn't necessarily be fair to the other providers if the indigent care was spread and the reimbursement for that was not," said Andrew Lasser, chief executive officer of St. Joseph Hospital.

"The first thing is all the hospitals, including our hospital, already provide significant amounts of indigent care," said Michael Kerner, chief executive officer of Doctors Hospital. "The hospitals and the providers are willing to help, but we can't be the only ones carrying the ball."

That's what happened when Medical Association of Georgia tried a voluntary indigent care program among its members in the early '90s, said Dr. Cook, who picked up some of the patients.

"The problem was you would see them and give them prescriptions and they couldn't afford to fill the prescriptions," Dr. Cook said. "There was no setup (for other care). This effort we saw (in Asheville) is a much more coordinated, comprehensive, cover-all-the-bases kind of approach."

University and Medical College of Georgia Hospital and Clinics, the largest indigent care providers in the area, had pursued a planning grant from the Robert Wood Johnson Foundation to conceive a new indigent care program that would be more similar to a managed care insurance program, said Don Snell, chief executive officer of MCG Health Inc. The idea stalled when the grant didn't come through, but it is still a viable alternative, Mr. Snell said. And the indigent care burden gives them a powerful incentive to work together.

"Both of us feel enough pain here where we would look for opportunities to cooperate with each other," Mr. Snell said

Continuing a contract

Whatever the new direction, it appears it will not come in time to avoid continuing the current certified indigent program contract with University for another year, said Commissioner Jerry Brigham, who is chairman of the indigent care subcommittee. And it probably means having only about the $1.25 million in this year's contract to offer again to University, Mr. Brigham said.

"I don't expect it to exceed that," if even that much is available, Mr. Brigham said.

University has not discussed numbers with the commission, Mr. Read said. But he expects things to be different.

"In the past, it's been contentious, and that's not helpful to our organizations," Mr. Read said. "Understanding each other's issues is what's going to make it better as we go forward. We're all trying to do the same thing, which is take care of this very special group of patients. That's the bottom line. We just need to work a little better to cause that to happen."

"It probably gives us some flexibility in that we know that there may be a way out of this annual confrontation so that both sides will come to the table with some flexibility," Mr. Shepard said. "If we can both see the light at the end of the tunnel, that's going to be good for both of us."

Back at the Center for Community Health, Ms. Sullivan gets the good news that her blood sugar level is back in the normal range and the test may have been a fluke.

"They said it was probably all that sweet lemonade I drank," she said.

Mrs. Henderson laughs as she puts her stethoscope on Ms. Sullivan's back, listening carefully, keeping an eye on her patient.

Buncombe County (N.C.) Medical Society Project Access is a physician-led effort to create a comprehensive health system for the poor and uninsured around Asheville.

About 500 physicians volunteer to take a certain number of indigent patients a year, 10 for a primary care physician and 20 for a specialist, carefully tracked through a computer system. Primary care is delivered at the Buncombe County Health Center and area clinics. Hospitals in Asheville donate lab services, outpatient care and hospitalizations. Area pharmacists donate drugs at cost, which are paid for by the county. The program has been so successful that other communities, such as Sedgwick County (Wichita) in Kansas, have adopted the model. A quick glance at the programs:

Asheville:

In the most recent fiscal year, 13,000 of an estimated 15,000 uninsured at or below 200 percent of the federal poverty level received primary care. Buncombe County Health Center saw 9,000 of those patients, and about 400 regularly see private physicians.

Physicians receive about 3,000 referrals a year, and donate services worth about $3.5 million a year.

Hospitals donate about $2 million in services a year. The program actually has cut their uncompensated care costs 15 percent in 2´ years.

The county paid $350,000 for prescription drugs at cost, worth more than $400,000 a year. Clinics also provide prescriptions.

25 percent of patients sampled said their health had improved enough to go back to work. The number of patients working increased from 33 percent to 44 percent.

Wichita:

Sedgwick County began its Project Access program in September 1999. Through Sept. 22, the program: